BlueChoice Opt-Out Open Access - Your Member Handbook

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					                                                             CareFirst BlueChoice, Inc.
                                         BlueChoice Opt-Out
                                                Open Access
                                                     Your Member Handbook




                                           FirstHelp ® Health Care Advice Line: (800) 535-9700
VA FORM #: BOK5075-1S (12/09) web only
           BlueChoice Opt-Out
Thank you for choosing CareFirst BlueChoice, Inc.’s (CareFirst BlueChoice) BlueChoice Opt-Out
Plan. We are committed to providing our members and their families with the highest level of service
possible and hope that the information included in this handbook will assist you in understanding
your CareFirst BlueChoice benefits and options.

Please take a moment to review this information and then keep it in a safe place for future reference.
This booklet, along with your Summary of Benefits and enrollment materials, gives you tips on
how to receive the highest level of health care benefits. This guide is meant to be an overview and
describes important features of BlueChoice Opt-Out. However, it is not a contract. A detailed
description of specific terms, as well as the conditions and limitations of your coverage, is included
in your Evidence of Coverage.

As always, please contact Member Services at the telephone number listed on the front of your
member identification card if you have any questions regarding your coverage. We appreciate
your business and look forward to serving you in the future.




                           Keep in a safe place for future reference.




      You may also view this handbook online at www.carefirst.com in the Members & Visitors section.


                                                                                                         i
                          Important Information
                                                                   Emergency Assistance and
        Member Services                                            Medical Advice
        Please contact Member Services at the telephone            In case of a medical emergency, call 911 or go to the
        number listed on your member identification                 emergency room. You should call your physician when
        card. Our service hours are:                               you have a health problem. If you cannot reach your
                                                                   physician and have questions about your health, an
              Monday – Friday, 7:00 am – 7:00 pm EST               illness or an urgent medical condition, FirstHelp®
              Saturday, 8:00 am – 1:00 pm EST                      is available to help you make a decision concerning
                                                                   the most appropriate level of care.
        Multi-lingual translators are available for
        assistance through Member Services.                        FirstHelp® Health Care Advice Line
                                                                   (24 hours a day) Toll-free: (800) 535-9700
        Contact Member Services for benefit and
        contract information.                                      Hospital Authorization/Utilization
                                                                   Management
        When writing to CareFirst BlueChoice, always
        include your Member Identification Number.                  Your CareFirst BlueChoice provider should obtain
        Please address your correspondence to:                     any necessary admission authorizations for covered
                                                                   services. Toll-free: 866-PREAUTH (773-2884)
             CareFirst BlueChoice, Inc.
             P.O. Box 644                                          Mental Health/Substance Abuse Care
             Owings Mills, MD 21117-9998                           Call the telephone number on your identification card
                                                                   under the Mental Health/Substance Abuse Service and
                                                                   Authorization section. Assistance is available 24 hours
     Please refer to the Evidence of Coverage for specific terms,   a day, 7 days a week.
     conditions, limitations and exclusions.
                                                                   Additional Telephone Numbers
                                                                        Pharmacy Benefits (Argus Health Systems)*
                                                                        (800) 241-3371

                                                                        Vision Benefits (Davis Vision)*
                                                                        (800) 783-5602

                                                                        Away From Home Care®
                                                                        (888) 452-6403



                                                                   *Your coverage may not include these benefits. Refer to
                                                                   your Evidence of Coverage for details.




ii                                  FirstHelp ® Health Care Advice Line: (800) 535-9700
                                                     Contents
Welcome to BlueChoice Opt-Out ......................................................................................... 1
Frequently Asked Questions .................................................................................................. 2
When You Need Care ............................................................................................................. 5
     ■ Your Primary Care Physician ■ Medical Records ■ Scheduling Appointments
     ■ Canceling Appointments ■ Laboratory Services ■ In-Network Benefits

CareEssentials.......................................................................................................................... 8
     ■ Prevention ■ Vitality Newsletter ■ Get Healthy With My Care First
     ■ Great Beginnings Program for Expectant Mothers ■ Preventive Services Guidelines
     ■ Utilization Management ■ Hospital Care ■ Disease Management Programs ■ Case Management Program

Options Discount Program................................................................................................... 12
     ■ Discounts on Alternative Therapies and Wellness Services

Emergency and Urgent Care ................................................................................................ 15
     ■ Medical Emergencies ■ Urgent Care ■ FirstHelp® Medical Advice Line ■ Care When Traveling
     ■ BlueCard Program ■ Follow-Up Care ■ The Away From Home Care® Program

Seeing Mental Health Specialists ......................................................................................... 18
Additional Benefits ............................................................................................................... 19
     ■ Dental Benefits ■ Prescription Benefits ■ Vision Benefits

Administration of Your Plan................................................................................................ 22
     ■ Personal and Enrollment Changes ■ Filing a Claim for Reimbursement ■ Provider Reimbursement
     ■ Other Insurance ■ Member Satisfaction

Appeals Process ..................................................................................................................... 24
Your Coverage ....................................................................................................................... 25
     ■ Ending Your Coverage ■ Continuing Your Coverage ■ New Technology Assessment

Portability.............................................................................................................................. 26
Confidentiality ...................................................................................................................... 27
     ■ Our Responsibilities ■ Notice of Privacy Practices ■ Your Rights

Member Rights and Responsibilities ................................................................................... 28
     ■ Rights of Members ■ Responsibilities of Members

Definition of Terms .............................................................................................................. 29
Index ...................................................................................................................................... 31



                                                           www.carefirst.com                                                                      iii
           Welcome to BlueChoice Opt-Out
    BlueChoice Opt-Out offers the flexibility                  The diagram below explains the information on
                                                              the front of your card. Please take a moment to
    to receive care outside the HMO network.                  review your card. If any of the information is
    With this product, care can be provided and               incorrect, please contact our Member Services
                                                              Department immediately.
    coordinated by a primary care physician
    (PCP) when you select from the CareFirst
    BlueChoice Network.
                                                                                                                                5
    Your PCP provides preventive care and can help you
                                                                      1                                   6                 7
    obtain specialty care. By helping to coordinate your          1
                                                                                                        OPEN ACCESS
    care, your PCP ensures quality of care while reducing
    medical expenses. When your selected PCP provides             2        XIC000000000                   0A01   3
    or coordinates your care, you are using in-network                2
                                                                 4    3    JANET DOE
    benefits. You also use in-network benefits when you                      PCP NOT ON APPLICATION
                                                                  5   4
    see any other BlueChoice PCP or specialist. Unique            6        P5 S10 ER25 RX 7
    to this plan is that you don’t need a PCP referral for
    in- or out-of-network care. You may still need an
    authorization from the plan for some services.               This is a sample member ID card. Please review your actual
                                                                 card for your ID number and information specific to your coverage.

    Your BlueChoice Opt-Out Plan provides you with the
    ability to see doctors outside of our network and still           1    MEMBER SERVICES TELEPHONE NUMBERS
    have part of that care covered. If you choose to see a
                                                                      2    MEMBERSHIP IDENTIFICATION NUMBER
    non-CareFirst BlueChoice provider you are using your
    out-of-network benefits. You may need to pay for                   3    GROUP NUMBER
    the services at the time of the visit and file a claim
    for reimbursement. You will be responsible for a                  4    MEMBER’S NAME
    percentage of the plan allowance and any provider
    charges above that amount.                                        5    PRIMARY CARE PHYSICIAN’S (PCP) NAME

    Your Membership Card                                              6    COPAYMENTS
    By now you should have received your BlueChoice                        P= PCP
    Opt-Out membership identification card. Your ID                         S= SPECIALIST
    card identifies you as a CareFirst BlueChoice                           ER= EMERGENCY ROOM
    member and contains important information about                        RX= PRESCRIPTION
    you, your primary care physician (PCP), your
    copayments and some of the benefits for which you                  7    DENTAL COVERAGE, IF APPLICABLE
    are eligible. This is the card that you present to your
    PCP, a specialist or a hospital to receive care. Always      The back of the ID card includes medical emergency assistance
                                                                 and mental health/substance abuse telephone numbers, as well
    carry your membership card with you. (If you haven’t         as instructions and an address for filing claims and sending
    received your card yet, please use your copy of the          correspondence. If your ID card is lost or stolen, please contact
    CareFirst BlueChoice enrollment form.)                       Member Services immediately for a replacement. Remember to
                                                                 destroy any old cards and always present your current ID card
                                                                 when receiving services.




1                                FirstHelp ® Health Care Advice Line: (800) 535-9700
             Frequently Asked Questions
What is my ID card for?                                   How do I know which specialists I can use?
Your card is important to getting the most out of         Can I use any specialist listed in the CareFirst
your health plan. You will present your card when         BlueChoice Provider Directory?
you receive care. Always carry your member ID             You will receive the highest level of coverage
card with you.                                            when you see an in-network specialist. You can
For more information, see the section “Your Membership    check the Provider Directory on our web site at
Card” on page 1 of this handbook.                         www.carefirst.com, or contact Member Services
                                                          to verify if a specialist is in the CareFirst
How can I find out if a certain doctor is                  BlueChoice network.
a primary care physician with CareFirst
BlueChoice?                                               Can I change my primary care physician?
You can access our CareFirst BlueChoice Provider          Yes, you can change your primary care physician.
Directory on our web site at www.carefirst.com. You        Contact Member Services, and a representative will
can also call the Member Services telephone number        assist you. CareFirst BlueChoice must be notified and
on the front of your identification card to request a      must process the PCP change prior to the time you
CareFirst BlueChoice Provider Directory or a Member       receive care from the new PCP.
Services Representative can access this information       For more information, see the section “Changing Your
for you.                                                  Primary Care Physician” on page 6 of this handbook.
For more information, see the section “Selecting Your
Primary Care Physician” on page 5 of this handbook.       How can I find out if I have a particular benefit?
                                                          Your benefits are detailed in the Evidence of Coverage.
How do I obtain specialty care?                           You may also contact Member Services to obtain
Your primary care physician (PCP) can help to             specific information on contract benefits such as
coordinate your in-network care. However, a PCP           medical care, vision care, dental care, prescription
referral is not necessary for in- or out-of-network       benefits, etc.
care. You will pay less out-of-pocket by seeing an
in-network specialist.                                    I will be traveling out of town. What coverage
                                                          do I have?
For more information, see the section “No Referrals
                                                          When you are outside of the service area, in-network
Needed for Specialists” on page 6 of this handbook.
                                                          benefits are available for emergency or urgent care
Do I need a referral for specialists?                     only. When traveling, out-of-network benefits are
                                                          available for other covered services. In addition, if
No, you do not need a written referral from your PCP      you will be traveling for 90 days or more, you may
to seek care from a specialist. However, you or your      be eligible for the Away From Home Care® Program.
provider may need to obtain an authorization from
the plan for some services, including but not limited     For more information, see the sections “Emergency and
to hospital care.                                         Urgent Care” on pages 15-18, “The Away From Home
                                                          Care® Program” on page 17 and “Filing a Claim for
                                                          Reimbursement” on page 22 of this handbook.




                                                www.carefirst.com                                                  2
    Frequently Asked Questions




    If I need in-area emergency care,                                    Our Prevention tools are designed to help
    what should I do?                                                    you stay strong and healthy.
    If your situation is a medical emergency, call 911
    or seek help immediately at the nearest emergency
    or urgent care facility. In an urgent situation, we
    recommend that you contact your PCP for advice.                      Utilization Management helps ensure you
    If you are unable to reach your PCP, you may contact                 receive the right care at the right time in
    FirstHelp®, our 24-Hour Emergency Assistance and                     the right place.
    Medical Advice Service at (800) 535-9700.

    For more information, see the “Emergency and Urgent                  Disease Management assists members with
    Care” section on pages 15-18 of this handbook.                       chronic illnesses to make smart choices for
                                                                         healthy living.
    I have a dependent who will be going away to
    college. What coverage does he or she have?
    If the college is outside of the CareFirst BlueChoice                Case Management provides support
    service area, coverage is limited to emergency or                    to members when it is needed most.
    urgent care only. For more information, see the
    section “Emergency and Urgent Care” on pages 15-18
    of this handbook. Students who will be out of the
                                                             Look for the CareEssentials logos in this member
    area for 90 or more days may be eligible for the Away
                                                             handbook to learn more about how CareEssentials
    From Home Care® Program.
                                                             can work for you.
    For more information, see the “Away From Home Care®”
    section on page 17 of this handbook.                           What can I do to ensure I pay the
                                                                   lowest copay for my prescription?*
    Where should I go for covered
    laboratory services?                                           To ensure that you are paying the lowest
                                                                   copay for a prescription, you should check
    Members must go to LabCorp® for any laboratory
                                                                   the status of the drug on the CareFirst
    services in order to obtain in-network coverage for
                                                                   preferred drug list before:
    those services. LabCorp® is contracted to provide
    services for CareFirst BlueChoice members throughout           ■   You talk with your doctor about a refill
    Maryland, Virginia and Washington, DC.                             or a change in your medication.
    For more information, see the “Laboratory Services”            ■   You call the pharmacy to order a refill.
    section on page 7 of this handbook.
                                                                   ■   You order a prescription through
    What is CareEssentials?                                            mail order.
    CareEssentials is CareFirst BlueChoice’s Care
    Management program that provides you with the
    tools and resources that will help you stay healthy      *This information applies only to members whose
    or make you well.                                        prescription drug program is based on the CareFirst
                                                             BlueChoice preferred drug list (also called a formulary).




3                                 FirstHelp ® Health Care Advice Line: (800) 535-9700
                                                                                             Frequently Asked Questions




For example, if you check the status of your brand-         What kind of information can I find on
name drug and find out there is a generic equivalent on      “My Account”?
the CareFirst BlueChoice preferred drug list, we suggest
                                                            When you visit My Account on www.carefirst.com,
you talk with your doctor to see if a generic alternative
                                                            you can find information about your medical plan
is the right choice for you.
                                                            including who and what is covered, claims status, and
For more information on how to cut prescription             how much has been applied to your deductible if you
drug costs, see the “Prescription Drug” section on          have one. In addition, our secure e-mail feature will
pages 19-20 of this handbook.                               enable you to send inquiries to us.

                                                            To use My Account:
                                                            1. Go to the Members & Visitors section of
    What kind of information can I find                         www.carefirst.com and click on the My Account
    on www.carefirst.com?                                       button on the left.
    At www.carefirst.com you can:
                                                            2. Register using the membership number
    ■   Find out the latest member news                        located on your member ID card.
        and updates.

    ■   Download claim forms and privacy forms.

    ■   Learn how to get discounts on alternative
        therapies, vision and hearing services,
        fitness centers and more through the
        Options discount program.

    ■   Find a doctor who participates in
        your plan using our searchable
        provider directory.

    ■   Look up health and wellness information
        at My Care First.

    ■   Get Member Services phone numbers.

    ■   Read answers to more of your frequently
        asked questions.

    ■   Find benefit and eligibility information
        on My Account.

    ■   Order a new member ID card on
        My Account.




                                                  www.carefirst.com                                                       4
                             When You Need Care
    Your Primary Care Physician                                Selecting your primary care physician
    When you joined CareFirst BlueChoice, you should           You may choose a doctor who specializes in family
    have chosen a primary care physician (PCP) to be           practice, general practice, pediatrics, or internal
    responsible for your primary medical care. If you did      medicine as your PCP. Each member must choose
    not choose a PCP upon enrollment, please contact           a PCP from our CareFirst BlueChoice Provider
    Member Services. The name of the PCP currently             Directory at the time of enrollment. Your entire
    on file for you appears on the front of your CareFirst      family may select the same doctor, or each member
    BlueChoice ID card.                                        may choose a different doctor based on each
                                                               individual’s age or medical needs.
    Establishing a relationship with one doctor is the best
    way for you to receive consistent, quality health care.    You may select your PCP by reviewing our list of
    We encourage you to contact your PCP for an initial        participating PCPs in the CareFirst BlueChoice
    health assessment within 90 days of your enrollment.       Provider Directory, by visiting our web site,
    If you have any questions about scheduling your            www.carefirst.com, or by contacting Member
    appointment, please call your PCP’s office.                 Services. Our staff is ready to assist you in selecting
                                                               a physician, and we can provide you with information
                                                               about a doctor’s background and hospital affiliation.
                                                               You can obtain specific information about a
        We encourage you to find a physician whom               physician’s practice style and office hours directly
        you feel comfortable with and schedule all             from the physician’s office.
        of your appointments with him or her.

        Your PCP will:

        ■   provide basic medical care – treating
            illnesses and providing preventive care;

        ■   prescribe any medications you may require;

        ■   maintain your medical history; and

        ■   work with you to determine when you
            should see a specialist, and assist in the
            selection of a specialist.




5                                   FirstHelp ® Health Care Advice Line: (800) 535-9700
                                                                                                  When You Need Care




Changing your primary care physician                      Scheduling appointments
If you wish to change your PCP, contact Member            CareFirst BlueChoice physicians see patients in their
Services and give the representative the name of the      own offices. Always call for an appointment before
PCP to whom you want to switch. If the change is          visiting your physician and identify yourself as a
requested prior to the 20th of the current month, it      CareFirst BlueChoice member. Don’t forget to bring
will be effective on the first of the following month.     your member ID card to your appointment and
Requests received after the 20th of the current month     present the card to the receptionist. You should
will be effective on the first of the second month         always present your CareFirst BlueChoice member
following your request. For example, a request received   ID card whenever you seek care at your PCP’s or
on January 21 would be effective March 1. You will        specialist’s office or the hospital.
receive a new identification card with your new PCP’s
name. Please destroy your old member ID card once         CareFirst BlueChoice has set goals for providers in
the change becomes effective.                             our participating network regarding appointment
                                                          availability and office waiting times. For appointments
No referrals needed for specialists                       for non-symptomatic visits, such as preventive care or
Your PCP can coordinate your medical care and             routine wellness, we expect the doctor to schedule the
provide treatment for a variety of medical conditions.    appointment within four weeks.
You can also go directly to a specialist from those
listed by specialty type in your CareFirst BlueChoice     If you have an urgent problem, call your PCP as
Provider Directory. If a provider with the required       soon as possible, and the office staff will arrange an
specialty is not available within the CareFirst           appropriate time for you to be seen. For a
BlueChoice network, your PCP should contact               symptomatic (acute) problem, most offices try to
CareFirst BlueChoice to determine if authorization        schedule you within 24-72 hours or less, depending
is available for treatment by an out-of-network           on the urgency of the problem. The nurse or the
specialist. You don’t need a referral form for a          appointment staff at your doctor’s office will help
specialist visit. However, an authorization may be        you determine how quickly you need to be seen.
required by the Plan for some services. Please refer
to your Evidence of Coverage to determine your
authorization requirements.

Medical Records
Each physician’s office keeps a copy of your medical
records. If you are a new member, we encourage you to
transfer your previous medical records to your PCP’s
office. Transferring your records to your PCP’s office
will give your PCP easier access to your medical
history. Your previous physician may charge you a
fee for this transfer of records. Your medical records
are kept in confidence and will only be released as
authorized by law. Please refer to the “Confidentiality”
section on page 27 of this handbook for our guidelines
on the release of medical information.




                                               www.carefirst.com                                                       6
    When You Need Care




    Canceling appointments
    If you are unable to keep a scheduled appointment,          Examples of in-network care:
    call the physician’s office as soon as possible. Our
    physicians prefer at least 24 hours notice so they          ■   primary care physician visit;
    can offer your appointment time to another patient.
    Some physicians may charge a fee if you miss an             ■   CareFirst BlueChoice specialist visit;
    appointment and have not called to cancel.
                                                                ■   diagnostic services, such as labs or
    Laboratory Services                                             x-rays, performed by CareFirst BlueChoice
    Members must go to a LabCorp® facility for any                  independent laboratories or radiology
    laboratory services in order to obtain coverage for             centers; and
    those services. LabCorp® is contracted to provide
                                                                ■   hospitalization when authorization is
    services for CareFirst BlueChoice members throughout
    Maryland*, Virginia and Washington, DC.                         obtained by your PCP or another CareFirst
                                                                    BlueChoice PCP or specialist.
    Labwork performed in an outpatient hospital setting
    will require a prior authorization.

    Before going to the LabCorp® site, members must
    have a LabCorp® requisition form or physician’s order
    on a prescription pad or letterhead.

    LabCorp® has approximately 70 locations in the
    Maryland, Washington, DC and northern Virginia
    area. If you need more information or need assistance
    with lab requisitions, please call LabCorp® at (800)
    322-3629. To locate the nearest LabCorp® patient
    service center, call (888) LAB-CORP (522-2677), or
    visit the LabCorp® web site at www.labcorp.com.

    *Some exceptions apply in Western Maryland.

    In-Network Benefits
    In-network care can be provided and coordinated
    by your primary care physician (PCP). You may also
    self refer to another CareFirst BlueChoice PCP or
    specialist. Visits to a specialist are considered
    in-network as long as you use a CareFirst BlueChoice
    specialist. Generally, you only pay a nominal
    copayment to a PCP, specialist or urgent care center
    when you use in-network benefits. The PCP
    copayment will apply when services are received
    from any CareFirst BlueChoice PCP. If you see a
    specialist, you will pay the specialist copayment.
    Covered diagnostic services are paid in full when
    received at participating facilities.




7                                FirstHelp ® Health Care Advice Line: (800) 535-9700
             Frequently Asked Questions
                   CareEssentials

           Prevention                                      heart health center for the information, quizzes and
                                                           tools to help manage these conditions.
          Visit My Care First, the health and
          wellness section of www.carefirst.com for         You can also obtain personalized health information,
information that can help you manage your health.          such as your body mass index, your target heart rate
                                                           and your ideal weight by using the health calculator.
   At My Care First you will find:                          For even more detail about your health, you can
                                                           register with the site. Registering will enable you
   ■   Information on over 300 health-related topics       to take a personalized health assessment, set health
                                                           goals, track your progress and have reminders sent
   ■   Personalized health calculators that determine      via e-mail. You can even get help to manage weight,
       your body mass index or target heart rate           stress or blood pressure and to quit smoking.

                                                           To visit My Care First, go to www.carefirst.com
Vitality Newsletter                                        and click on “Health and Wellness – My Care First”
You may receive Vitality, our quarterly member             in the Solution Center.
newsletter. Vitality can give you the tools you need to
help you achieve a happier and healthier lifestyle. Each   Great Beginnings Program for
issue is filled with useful and timely information on       Expectant Mothers
a variety of health-related topics. You’ll learn about     CareFirst also offers Case Management support to
food and nutrition, physical fitness, recreation and        members during pregnancy. The Great Beginnings
preventive health care. You will also get to know          program is designed to supplement the prenatal care
about our company and how to get the most from             and education you receive from your doctor during
your benefits.                                              pregnancy. Our Case Managers strive to help you
                                                           and your baby stay healthy during pregnancy.
Get Healthy with My Care First
Looking for ways to get healthy and stay healthy? Go       When you enroll in Great Beginnings, one of our
surfing–on the web, that is. Visit My Care First, the       Case Managers will contact you to review your
health and wellness section of www.carefirst.com.           medical history and to identify any other conditions
Our award-winning site contains a wealth of health         that may affect your pregnancy. You will receive
information and interactive features that can help         information related to your condition and your baby’s
you take an active role in managing your health.           development. Your Case Manager will contact you
                                                           during each trimester to see how you are feeling and
If you are looking for information about a specific         to answer any questions.
condition, just select a topic from our health library.
You can also learn about a variety of health issues        If you have not chosen a pediatrician, the Case
from our weekly stories, quizzes and Health Scout          Manager also may assist you in finding a pediatrician
news, which is updated several times a week. You also      close to your home. If you experience any
can offer your opinion on a health issue by taking         complications during pregnancy, your Case Manager
the weekly poll.                                           will work closely with your doctor to coordinate
                                                           necessary services and provide additional support
If you or a loved one has asthma, diabetes or heart        and information you may need during this time.
disease, visit our asthma center, diabetes center or

                                                 www.carefirst.com                                                 8
    CareEssentials




    Case Managers are available to answer questions,           If you would like a list of the specific
    Monday through Friday, 8:30 am to 4:30 pm.
    To find out more information about the program,
    call (888) 264-8648.                                       guidelines, call Member Services at the

                                                               number listed on your member ID card.
        Preventive Services Guidelines
                                                               You may also visit our web site at
        Each year, CareFirst BlueChoice publishes a list of
        preventive services guidelines. Preventive services
        are procedures you should have, if applicable, to      www.carefirst.com and click on
        detect any health problems. Your physician
        may recommend additional tests or exams.               My Care First.
        Adult preventive services include:

        ■   periodic physicals

        ■   blood pressure checks

        ■   height and weight monitoring

        ■   cholesterol testing

        ■   colon and prostate cancer testing

        ■   gynecological exams

        ■   testicular exams

        ■   diabetes screening

        ■   mammograms

        ■   immunizations

        The preventive services for children include:

        ■   periodic physicals

        ■   blood pressure checks

        ■   height and weight monitoring

        ■   hearing and vision screenings

        ■   cholesterol and TB tests

        ■   growth, development and behavior assessments

        ■   immunizations




9                                   FirstHelp ® Health Care Advice Line: (800) 535-9700
                                                                                                        CareEssentials




             Utilization Management                       If you do not transfer to a CareFirst BlueChoice
                                                          hospital when medically able to do so, you will be
            Utilization Management ensures that care
                                                          financially responsible for the remaining charges of
            is provided at the right time and in the
                                                          that hospitalization. A list of participating CareFirst
proper setting. Registered nurses and board-certified
                                                          BlueChoice hospitals can be located in the CareFirst
practitioners administer CareFirst BlueChoice’s
                                                          BlueChoice Provider Directory, or at our web site,
Utilization Management Program.
                                                          www.carefirst.com.
The program includes prior authorization                  Out-of-Network
requirements for certain services; review of
authorizations for hospital admissions according          When the admitting physician does not participate in
to a nationally-accepted set of criteria; and             the CareFirst BlueChoice network, you are responsible
retrospective review of treatment for which CareFirst     for obtaining authorization from CareFirst BlueChoice.
BlueChoice did not give prior authorization.              Failure to do so may result in a reduction or denial of
                                                          benefits. Authorizations for hospitalizations will be
Hospital Care                                             provided only if treatment cannot be provided on an
In-Network
                                                          outpatient basis. At the time of treatment, you may
                                                          need to provide payment in full to the hospital, doctor,
If you need to be hospitalized, your primary care         or other covered providers. Use of your out-of-network
physician (PCP) or CareFirst BlueChoice specialist will   benefits generally results in a greater out-of-pocket
select a hospital and will make arrangements for your     expense to you. You are responsible for a percentage of
admission. The hospital selected will usually be where    CareFirst BlueChoice’s allowance for covered services
your PCP or specialist has admitting privileges.          and for any balances up to the provider’s charge.
Discuss all the details of your admission in advance      Obtaining Authorization
with your PCP or CareFirst BlueChoice specialist.
                                                          Authorization must be obtained at least five business
You may want to ask about details such as length
                                                          days before the anticipated date upon which
of stay, special diets or procedures. Knowing the
                                                          treatment will start or the admission date for an
answers in advance can make your stay easier and
                                                          elective or planned hospitalization. If the admission
more comfortable.
                                                          cannot be scheduled in advance because it is not
Some outpatient hospital procedures, such as              medically feasible to delay the admission for five
outpatient diagnostic services, pre-admission testing     business days due to the member’s medical condition,
or surgery, may be subject to approval by CareFirst       we must receive notification of the admission as soon
BlueChoice. Again, your CareFirst BlueChoice              as possible. Authorization for an emergency admission
admitting physician will coordinate with CareFirst        must be obtained within 48 hours of the admission or
BlueChoice regarding authorization requirements.          by the end of the first business day following the
When you fill out the admission or registration papers     beginning of the admission, whichever is earlier.
at the hospital, be sure to indicate that you have
                                                          In-Network: Requirements are handled by your
coverage through CareFirst BlueChoice.
                                                          CareFirst BlueChoice providers. Your PCP or the
In-network benefits will not be provided for services      CareFirst BlueChoice specialist who admits you to the
rendered in a non-CareFirst BlueChoice hospital,          hospital in conjunction with the hospital is responsible
except in certain emergency situations. If you are        for obtaining the authorization.
admitted to a non-CareFirst BlueChoice hospital,
                                                          Out-of-Network: When using out-of-network benefits,
you may be transferred to a CareFirst BlueChoice-
                                                          you or your representative must call Utilization
approved hospital as soon as medically feasible.
                                                          Management at (866) PREAUTH (773-2884) (this
                                                          telephone number is also on the back of your member
                                                          ID card). Failure to do so may result in a reduction or
                                                          denial of benefits. Utilization Management office hours
                                                          are 8:30 am to 7:00 pm (EST), Monday through Friday.




                                               www.carefirst.com                                                         10
     CareEssentials




     Continued Stay Review                                     Case Managers are registered nurses who play an active
     After your hospital admission has been authorized, a      role in working with your primary care physician to
     Care Management nurse, working in conjunction with        help develop a plan of care that will ensure that you
     a CareFirst BlueChoice Medical Director, will review      receive the best possible care in an efficient and timely
     your admission to determine if additional inpatient       manner. Your relationship with your Case Manager
     hospital days are medically necessary. This type of       enables you to receive prompt answers to any of your
     review is known as Continued Stay Review. Your            questions or concerns.
     physician, a hospital representative and the Care
     Management nurse will coordinate the approval of          Please keep in mind that since this program is
     additional hospital days. The Care Management nurse       voluntary you can withdraw at any time without
     can also assist with discharge planning as needed.        a penalty.
     If it is determined that extra days are not medically
     necessary, your doctor will be notified.
                                                                     When appropriate, Case Management can
                      Disease Management Programs                    help you with conditions such as (but not
                 Disease Management Programs provide                 limited to):
                 eligible members with educational
     materials and reminders that enable them to manage              ■   Spinal Cord Injury
     chronic diseases. In more serious cases, Case Managers
                                                                     ■   Amputation
     make telephone contact with members and their
     doctors. CareFirst BlueChoice has programs for                  ■   AIDS
     asthma, COPD, diabetes and heart disease.
                                                                     ■   Asthma
     Members who enroll receive educational materials that
     will help them better understand and manage their               ■   Burns
     condition. Members are also given telephone access
                                                                     ■   Cancer
     to a nurse who can answer their questions about
     medications, tests their doctor ordered or other                ■   Diabetes
     concerns related to their condition. All of these
     programs are voluntary and are provided at no                   ■   Heart Disease
     additional cost to eligible members.
                                                                     ■   High Risk Newborns
                      Case Management Program
                                                                     ■   High Risk Pregnancies
                 When faced with health care decisions, you
                 and your family may have many questions             ■   Multiple Fractures
     and difficult choices to make. The Case Management
     Department of CareFirst BlueChoice wants to make                ■   Severe Head Trauma
     sure you get all the help you need for any health
                                                                     ■   Stroke
     problems or concerns you may have.

     The Case Management Program is part of your
     medical benefits. As a member of CareFirst                 If you want to enroll or would like more information
     BlueChoice, you will not be charged any fee for this      about the Case Management Program, please
     service. It’s one of the ways we can help you to remain   call (888) 264-8648, Monday through Friday
     active and in the best health possible.                   between 8:30 am and 4:30 pm.




11                                 FirstHelp ® Health Care Advice Line: (800) 535-9700
             Options Discount Program
             Frequently Asked Questions
Options is a discount program provided to members of         members only. If you are already a club member (or
CareFirst BlueChoice. Because this is a discount program     were a member in the last 90 days**) you are not
and not a covered benefit, there are no claim forms,          eligible for the discounted rate. The only exception
referrals or paperwork. To receive these discounts, simply   is Bally Total Fitness. After you have completed
show your BlueChoice ID card or visit the special website    your current Bally contract, you are eligible for the
for members if it’s an online program. In order to be        discounted rate.
responsive to your needs, Options continually adds new
services. Visit www.carefirst.com/options for the latest      ** There are a limited number of clubs that require a
Options programs.                                            longer “run-out” period than 90 days. Please contact
                                                             GlobalFit for more information.
Discounts Include:
                                                             Healthways WholeHealth Networks offers a
Weight Loss Assistance Programs                              nationwide network of approximately 2,900 fitness
                                                             centers and spas. With your CareFirst BlueChoice
Weight Watchers, one of the nation’s most recognized         plan, you can receive discounts on the following:
weight loss programs is online, and CareFirst
BlueChoice members can save $10 on a 3-month                 ■ 10-50% off fitness center initiation fees and/or
subscription to Weight Watchers Online®. Weight                membership dues
Watchers Online® provides a set of personalized              ■ Spa memberships or services ranging from 10-30%
weight loss tools, such as Online Journal, Meal
Planner, Weight Tracker, and Progress Charts. Search         NOTE: Membership obligations for fitness centers
a database of more than 800 Weight Watchers recipes          and discounted spa services are based on individual
and calculate POINTS® for your own foods and meals.          location policies.
Join Jenny Craig and receive a FREE 30-day program*.         National Fitness Network consists of approximately
Jenny Craig will design a personalized comprehensive         100 independent regional health clubs*** and is the
program with one-on-one support, that fits your lifestyle.    only health club network that offers the convenience
You can also enjoy up to 50% off the 6-month program*        of unlimited access to its entire network of clubs with
or 20% off the 1-year Premium Success Program*.              a single membership. There is no need to select a
                                                             primary club or transfer your membership. National
* Plus the cost of food and shipping when applicable.        Fitness Network offers the following discounts:
Discounts apply to membership fee only. Offer good at
participating Centres and Jenny Direct® in the United
States, Canada and Puerto Rico.
                                                                 and $29 for each additional family member.
Fitness Club Memberships
Through 3 different networks, Options offers                 NOTE: To receive a discount, you must enroll directly
flexibility in choosing a gym that is right for you.          through the National Fitness Network. If you are
With GlobalFit’s lowest price guarantee, you’ll receive      already a member of a National Fitness Network club,
the best available rates at more than 10,000 fitness          you must complete your current contract before you
clubs nationwide, including Bally Total Fitness clubs        can get the discounted rate.
and Curves, all with month-to-month memberships
and no long-term contracts.                                  ***Available in MD, DC, VA, NJ, and FL only.
NOTE: Discounts in GlobalFit clubs are for new


                                                  www.carefirst.com                                                    12
     Options Discount Program




     Hearing Care Services                                        ElderCare Information & Referral Program
     Better hearing enriches your quality of life. Take           ElderCarelink is a free, internet-based service that
     advantage of the many discounted services offered by         specializes in providing referrals for services for elders
     both Beltone Hearing Care Centers and TruHearing.            and their families. Services include home health care,
     With Beltone, parents, children, spouses and                 home support, assisted living, adult day care, long-
     grandparents receive free hearing screenings and a 25%       term care, nursing home options and more. Members
     discount off the cost of Beltone hearing aids. All Beltone   fill out a needs assessment online survey and then
     hearing aids include free batteries for one year, a two-     ElderCarelink will e-mail a list of participating
     year warranty, free cleaning and minor repairs and           network providers that match your needs. Members
     adjustments for the life of the hearing aid. TruHearing      are also eligible to receive a free 90-day subscription
     offers free hearing screenings and discounts of up to 60%    to The Caregiver’s Home Companion newsletter.
     off quality digital instruments for CareFirst BlueChoice
     members, their children, parents, and grandparents.          Alternative Health & Wellness Services
     TruHearing also offers an extended two-year warranty
     and a 45-day money back guarantee. All hearing tests are     The following services are offered through Healthways
     performed using the latest diagnostic equipment.             WholeHealth Networks, Inc. Through the Options
                                                                  program, members can receive up to a 30% discount
                                                                  on these alternative health and wellness services.
     Laser Vision Correction & Contact Lenses
                                                                  ■ Acupuncture                 ■   Mind-Body
     Through TruVision, CareFirst BlueChoice members
                                                                  ■ Chiropractic Care               Instruction
     can receive 10% off of LASIK or PRK procedures.
                                                                  ■ Guided Imagery              ■   Nutrition Counseling
     All pricing includes a pre-operative exam, the Laser
                                                                  ■ Magazine Discount           ■   Personal Training/
     Vision Correction procedure, post-operative care
                                                                    Program                         Pilates
     and a one-year enhancement warranty. Discounts
                                                                  ■ Massage Therapy             ■   Qi Gong/Tai Chi
     are also available on Custom LASIK, IntraLase
                                                                  ■ Meditation Instruction      ■   Yoga
     Bladeless procedures, and some centers offer lifetime
     re-treatment plans. Members can also receive
     discounts of up to 50% off most brands of contact
     lenses ordered through the Mail and receive free
     shipping and handling.

     QualSight provides affordable access to quality laser
     vision correction services at 600 locations nationwide.          In addition to the Options program, the Blue
     QualSight partners with leading ophthalmologists                 Cross and Blue Shield Association gives you ac-
     and credentials each doctor in order to verify their             cess to even more discounts through Blue365.
     experience and work history. Included in the $895 price          Blue365 provides tools and guides to help you
     per eye are the pre-operative exam, LASIK or PRK                 learn more about wellness services that go be-
     procedure, post-operative exams, and a retreatment               yond your covered services. There are four key
     warranty. Discounts are also available on Custom                 areas of Blue365:
     LASIK, Conductive Keratoplasty, and IntraLase.
                                                                      ■   Health and Wellness
     Medical IDs                                                      ■   Family Care
                                                                      ■   Health-Focused Financial Services
     American Medical ID offers a 22% discount on                     ■   Travel Information
     customized medical identification bracelets and
     necklaces. Medical IDs allow medics or other medical             Want to know more about what Blue365 has
     professionals to give prompt, precise treatment in a             to offer? Look for the list of Blue365 vendors
     medical emergency. They help ensure a patient will               and resources on a special Web site designed
     receive proper care, eliminate unnecessary testing               just for BlueChoice members. It’s all available
     and reduce the chance of costly medical errors. Those            at www.carefirst.com/options. You can also
     who have chronic medical conditions, drug or food                call Member Services for more information
     allergies, or are taking multiple medicines, are advised         on Blue365.
     to wear a medical ID.

13                                 FirstHelp ® Health Care Advice Line: (800) 535-9700
                                                                                       Options Discount Program




Visit www.carefirst.com/options for more information on these services or see the following
contact information below.


    Options Program Directory
    Alternative Health           Healthways WholeHealth Networks, Inc. (800) 514-6502
    & Wellness Services          http://options.wholehealthmd.com

    Eldercare Information        ElderCarelink (866) 451-5577
    & Referrals                  www.eldercarelink.com/carefirst
                                 GlobalFit (800) 294-1500
                                 www.globalfit.com

                                 Healthways WholeHealth Netowrk (800) 514-6502
    Fitness Centers              http://options.wholehealthmd.com

                                 National Fitness Network (800) 811-5454
                                 www.nationalfitnessnetwork.com
                                 Beltone (800) 235-8663
                                 www.beltone.com
    Hearing Care
                                 TruHearing (877) 587-3937
                                 www.truhearing.com
                                 QualSight LASIK (877) 285-2010
                                 www.qualsight.com/-carefirst
    Laser Vision Correction
                                 TruVision LASIK* (800) 398-7075
    & Contact Lenses
                                 www.truvision.com/carefirst/LASIK.htm
                                 *Also offers discounts on mail-order contact lenses

                                 American Medical ID (800) 363-5985
    Medical IDs                  www.americanmedical-id.com/extras/carefirst.php
                                 Weight Watchers Online®
    Weight Loss                  www.weightwatchers.com/cs/cfbcbs
    & Management                 Jenny Craig® (800) 96-JENNY
                                 www.jennycraig.com/corporatechannel/carefirst.aspx




                                          www.carefirst.com                                                       14
                  Frequently and Urgent Care
                  Emergency Asked Questions
     When you have a medical emergency, your health care
     coverage is not the first thought that comes to mind.
     We encourage you to become familiar with this section          Urgent Care
     so you’ll know how to get the maximum benefits                  An “Urgent Condition” is a condition that
     available under the policy if you should have a                is not a threat to life or limb, but does
     medical emergency.                                             require prompt medical attention.

                                                                    If the situation is urgent:

                                                                    ■   Contact your PCP. If your PCP is
          Medical Emergencies
                                                                        unavailable or if you are unsure about
          If the situation is a medical emergency:                      the meaning or seriousness of the
                                                                        symptoms, you can call FirstHelp® at
          ■   call 911 or                                               (800) 535-9700 for medical advice
          ■   go directly to the nearest
                                                                        or
              emergency facility.
                                                                    ■   Go directly to an urgent care center. A
                                                                        list of participating CareFirst BlueChoice
          A “Medical Emergency” is the sudden onset
                                                                        Urgent Care Centers can be found in the
          of a serious illness or injury that in the
                                                                        CareFirst BlueChoice Provider Directory
          absence of immediate medical attention
                                                                        or on our web site at www.carefirst.com.
          could reasonably be expected by a prudent
          layperson (one who possesses an average
          knowledge of health and medicine)
          to result in:
                                                               Urgent Care Centers
          ■   serious jeopardy to the patient’s health;        Urgent care centers are walk-in medical facilities
                                                               equipped to handle minor emergencies. Most centers
          ■   serious impairment to bodily functions;          have evening and weekend hours should a condition
                                                               require immediate attention and you are unable to
          ■   serious dysfunction of any bodily organ          reach your PCP. Urgent care centers are typically
              or part; or                                      conveniently located and often allow you to be seen
                                                               more quickly than in an emergency room.
          ■   in the case of a pregnant woman, serious
              jeopardy to the health of the fetus.             You may refer to the list of urgent care centers in
                                                               your CareFirst BlueChoice Provider Directory or
                                                               call FirstHelp® for a participating urgent care
                                                               center near you.
     An authorization is not needed for emergency
     room services.                                            Remember, urgent care centers do not take the place
                                                               of your PCP. Your PCP should be your first contact
                                                               whenever you need medical care.




15                                  FirstHelp ® Health Care Advice Line: (800) 535-9700
                                                                                               Emergency and Urgent Care




FirstHelp®: 24-Hour Emergency
Assistance and Medical Advice                                    Care When Traveling
If you believe a situation is a medical emergency, call          ■   Seek medical attention immediately in the
911 immediately or go to the nearest emergency                       case of emergencies and urgent conditions.
facility. In an urgent situation, contact your PCP for
advice. If your PCP is not available and you have                ■   If you are unsure about the meaning or
symptoms and don’t know exactly what they mean or                    seriousness of the symptoms, call FirstHelp®
how serious they are, CareFirst BlueChoice provides                  at (800) 535-9700 for medical advice.
you with FirstHelp®, a 24-Hour Emergency Assistance
and Medical Advice hotline. Here’s how it works:

1. If you are unable to reach your PCP, call FirstHelp®,     BlueCard® Program
   our 24-Hour Medical Advice/Emergency Assistance           As a CareFirst BlueChoice Opt-Out member, your
   Service at (800) 535-9700. (The telephone number          benefits include the BlueCard® program for out-of-
   is also listed on the back of your identification card.)   area emergency and urgent care situations. The
   Your call will be answered promptly by an                 BlueCard® program is a benefit because when you
   experienced registered nurse.                             see an out-of-area participating Blue Cross and Blue
                                                             Shield physician or hospital for emergency or urgent
2. If the nurse determines that your situation is a          care, you will only be responsible for paying out-of-
   medical emergency, he or she will advise you to           pocket expenses (copayment), and your benefits will
   seek immediate medical care. NOTE: If taking the          be paid at the in-network level. This relieves you of the
   time to call FirstHelp® would seriously jeopardize        hassle and worry of paying for the entire visit up-front
   your health, call 911 directly or go to an emergency      and then filing a claim form later. The participating
   facility immediately.                                     BlueCross BlueShield physician or hospital will file the
                                                             claim directly to the local BlueCross BlueShield plan.
3. If your condition is not an emergency situation, the      In turn, the participating provider will be reimbursed
   nurse will ask you about your symptoms. The nurse         directly on your behalf.
   will then make recommendations to help you decide
   the safest and most appropriate course of action,         To use the BlueCard® program for out-of-area
   whether it’s a participating urgent care center, an       emergency and urgent care, please call (800) 810-BLUE
   appointment at your PCP’s office, or self-care.            (2583) to locate the nearest Blue Cross and Blue Shield
                                                             physicians and hospitals. At the time of service,
4. If the nurse recommends self-care, he or she will         present your member ID card.
   educate you about your condition, explain what to
   do for pain or symptom relief and tell you what to        If you do not use the BlueCard® program for out-of-
   expect or watch for. The nurse may also call you the      area emergency or urgent care, the physician or hospi-
   next day to check on your condition.                      tal should bill CareFirst BlueChoice directly. However,
                                                             if an up-front payment is requested, obtain itemized
If your urgent condition is related to mental health or      receipts and contact Member Services when you return
substance abuse, see the section “Seeing Mental Health       to obtain a claim form for consideration and
Specialists” on page 18 of this handbook.                    reimbursement of charges.

                                                             For more information, see the section on “Filing a Claim
                            ®                                for Reimbursement” on page 22 of this handbook.
                FirstHelp 24-Hour
          Emergency Assistance and
             Medical Advice Hotline
                  (800) 535-9700



                                                  www.carefirst.com                                                        16
     Emergency and Urgent Care




     Follow-Up Care                                             The Coordinator will:
     If your condition requires follow-up care after your       1. Check your CareFirst BlueChoice eligibility.
     initial visit to an urgent care center or hospital
     emergency room, you should contact your PCP.               2. Obtain the appropriate information
     In-network benefits may not be available for                   (e.g., destination, duration of stay).
     follow-up care performed in an urgent care center
     or hospital emergency room for additional services         3. Determine if there is a participating affiliated HMO
     related to the initial condition.                             available in the area where you or your dependents
                                                                   are visiting. If there are no participating affiliated
     In-network benefits are applied to medical emergency           HMOs in the area, the program will not be
     care. In most cases, out-of-network benefits will be           available to you.
     applied to follow-up care received at an urgent care
     center or hospital.                                        4. Explain how the program works if there is an
                                                                   affiliated HMO available in the destination area.
     The physician at the emergency room or urgent care
     center cannot refer you to a specialist for follow-up      5. Send the application to you for your signature, and
     care. You should contact your PCP for a referral to a         once the signed application is returned, submit it
     specialist. You can always contact Member Services to         to the affiliated HMO.
     determine if you are following the correct procedures
     to receive the highest level of benefits.

     The Away From Home Care® Program
     The Away From Home Care® program allows CareFirst
     BlueChoice members and their dependents to receive
     care when they are away from home for at least 90
     days. The care can be provided by an affiliated Blue
     Cross and Blue Shield HMO outside of the CareFirst
     BlueChoice service area (Maryland, Washington, DC,
     and northern Virginia). Whether it is extended
     out-of-town business or travel, semesters at school or
     families living apart, with the Away From Home Care®
     program, members can enjoy a full range of benefits.
     This includes, but is not limited to routine and
     preventive care. Your copay and benefits will be those
     of the affiliated HMO in the area where you are
     visiting. You will be treated as though you are actually
     a member of the affiliated plan.

     Where can I obtain more information and enroll
     in the Away From Home Care® program?
     If you would like to obtain more information or enroll
     in the Away From Home Care® program, please call
     the CareFirst BlueChoice Member Services number
     on the front of your CareFirst BlueChoice ID card and
     ask to be transferred to the Away From Home Care®
     Coordinator.




17                                FirstHelp ® Health Care Advice Line: (800) 535-9700
        Frequently Asked Questions
       Seeing Mental Health Specialists
Your health care coverage includes mental health and       This is especially important if you are receiving
substance abuse benefits. Mental health and substance       medications, since your PCP will then be able to
abuse benefits may be subject to day and/or visit           monitor potential interactions related to any other
limitations. Also, certain conditions may be excluded,     medications that may be prescribed for you. By
such as chronic, long-term or ongoing conditions.          working with your PCP and other practitioners, you
                                                           can assist in the continuity and effective coordination
Please consult your Evidence of Coverage for specific       of your health care.
information about your particular coverage, or call
Member Services for more information.                      To be eligible for in-network benefits, both mental
                                                           health and substance abuse services must be
How to obtain in-network mental health care                coordinated through our administrator. Please
If you think you are in need of mental health or           refer to your Evidence of Coverage to identify your
substance abuse care, you must first call the Mental        specific mental health and substance abuse benefits.
Health/Substance Abuse Service and Authorization
phone number on the back of your identification card.       For mental health and substance abuse care, including
A trained representative will ask you basic questions      emergencies, call the Mental Health/Substance Abuse
and explain your benefits. A Case Manager will              Service and Authorization telephone number on the
discuss your situation with you and evaluate the most      back of your identification card. Service is available
appropriate plan of treatment. If the patient is a child   24 hours a day, 7 days a week.
or an adolescent, the parent or guardian may provide
the necessary information.                                 How to Obtain Out-of-Network Mental
                                                           Health Care
Based on your discussion with the Case Manager,            You may self-refer for covered outpatient services
you may be referred to a mental health provider to         or partial hospitalization to any covered provider.
treat your condition. Once you have been referred,         However, for inpatient hospital admissions, you must
your network provider will work directly with the          first contact our mental health and substance abuse
Case Manager to obtain authorization for any               administrator for authorization.
additional treatment.

Mental health and substance abuse services must
be coordinated through our mental health and                   Exclusions
substance abuse administrator rather than through              ■   Depending on your contract, benefits might
your PCP. However, if you wish, you may first                       not be available for the services rendered
discuss your concerns with your doctor. Your PCP                   by all providers listed in the CareFirst
may contact our mental health and substance abuse                  BlueChoice Provider Directories.
administrator on your behalf. If you receive
ongoing care from a mental health practitioner, we             ■   Please refer to your Evidence of Coverage for
suggest that you have this practitioner send regular               specific information regarding exclusions
reports regarding your treatment directly to your PCP.             from your coverage.




                                                www.carefirst.com                                                    18
                         Additional Benefits
                     Frequently Asked Questions
     Dental Benefits                                             Preferred (PPO) Dental
     Your benefits may include dental coverage. Details          CareFirst’s Preferred (PPO) Dental offers both
     about your dental coverage are located in your             savings and choice. CareFirst has developed a
     Evidence of Coverage.                                      network of 3,400 preferred dentists who have agreed
                                                                to provide care at a discount. Once you meet your
                                                                annual deductible, you can save money by paying a
        If you have dental benefits, you have access to          lower coinsurance amount when using a dentist in the
        the following services:                                 Preferred network, and have no claim forms to file.
                                                                If you receive care outside the Preferred network, you
        ■   Preventive care                                     may have to file your own claim forms and pay more
                                                                out-of-pocket for your care.
        ■   X-rays
                                                                Dental HMO
        ■   Fillings and restorative services
                                                                The Dental Network, Inc. (TDN) is the administrator for
        ■   Oral surgery and periodontal care                   CareFirst’s Dental HMO (DHMO) plans. As a DHMO
                                                                member, you choose a Primary Care Dentist (PCD)
        ■   Emergency care                                      from a carefully selected network. All dental services
                                                                are provided for the cost of a copay – there are no
        Your dental coverage may also include orthodontia.      deductibles to meet, no claim forms to file and no
                                                                annual maximums. If you have not selected a PCD
                                                                or have questions about your DHMO dental
     For information on dental coverage, please call the        coverage, please contact TDN at (410) 847-9060
     Member Services phone number on front of your              or (888) 833-8464.
     member ID card or the Dental Member Services
     number located on the back of your identification card.     CareFirst BlueCross BlueShield is the business name
                                                                of Group Hospitalization and Medical Services, Inc.
     The following is a list of dental plans for which you      CareFirst BlueChoice and TDN are independent licensees
     may be eligible if you purchase coverage through your      of the Blue Cross and Blue Shield Association.
     employer. Members with individual coverage are only
     eligible for Dental HMO coverage.                          Prescription Benefits
                                                                Your coverage may include benefits for outpatient
     Traditional Dental
                                                                prescription drugs. Please review your Evidence
     CareFirst BlueCross BlueShield’s (CareFirst) traditional   of Coverage to determine whether or not you have
     Dental allows you the freedom to seek dental care          benefits for outpatient prescription medications
     from any dentist and the opportunity to reduce             under your BlueChoice Opt-Out plan.
     out-of-pocket costs. When you visit a participating
     dentist, you have no claims to file and are only
     responsible for applicable deductibles and coinsurance.
     If you seek care from a non-participating dentist, you
     will be required to file claims yourself and you may
     incur higher out-of-pocket costs. More than 3,800
     dentists participate with CareFirst – you may already
     be seeing a CareFirst participating dentist.



19                                   FirstHelp ® Health Care Advice Line: (800) 535-9700
                                                                                                     Additional Benefits




CareFirst BlueChoice uses a preferred drug list (also      Here are simple steps you can take:
called a formulary), which is a list of generic (tier 1)
and certain preferred brand-name (tier 2) drugs. Drugs     1. Know your out-of-pocket costs. Use the
that are not on the formulary are called non-preferred        online database or price comparison tool at
(tier 3) drugs and are covered as part of your plan,          www.carefirst.com to learn more about the
although your payment will be more for these drugs. If        costs of your medications.
you are prescribed a non-preferred brand-name drug,
discuss alternatives that are on the preferred drug list   2. Talk with your doctor. Print a copy of our current
with your doctor.                                             preferred drug list to bring to your next doctor’s
                                                              visit. Discuss the medicines you are taking and if
How often does the preferred drug list change?                they are on the preferred drug list. If your medicine
As often as needed, but usually no more than a few            is not on this list –a tier 3 or non-preferred brand
times each year. Drugs on the preferred drug list are         name drug– ask if there are more affordable
selected by a committee of practicing physicians and          alternatives that may be right for you.
pharmacists from the community and CareFirst
                                                           3. Use a participating pharmacy. There are more than
BlueChoice and are chosen because of their quality,           59,000 participating pharmacies nationwide that
effectiveness, safety and cost. The preferred drug list       accept your prescription drug card. Choose one
also changes as new drugs enter the market and                that’s convenient, but remember to shop around.
as generic equivalents become available.                      Some pharmacies charge more than others, and if
For the most current preferred drug list, please              you have a plan with coinsurance, those prices may
visit www.carefirst.com.                                       affect how much you pay.
Prior Authorization                                        4. Don’t forget your member ID card. To help ensure
Even if a drug is on our preferred drug list, it may          you receive proper service, the pharmacist will
still require advance approval, or prior authorization,       need your member ID card and a prescription
before it can be filled. The patient’s physician should        from your doctor.
begin the authorization process before they visit the
pharmacy. If prior authorization is not obtained or is     5. Be on the lookout for alternatives. New medicines
denied, the drug will not be covered. If you are already      become available often, so the price of your
at the pharmacy and find that the drug needs prior             prescription may rise or fall as a result. Changes
authorization, you should have the pharmacist call the        in the preferred drug list often happen because a
prescribing doctor and request that he/she begin the          new medicine is introduced to the marketplace
authorization process.                                        or a generic becomes available.

Questions                                                  Some of these tips apply only to members whose
Argus Health Systems (Argus), our pharmacy claims          prescription drug benefit is based on the CareFirst
processor, administers the CareFirst BlueChoice            BlueChoice preferred drug list.
prescription drug program. If you have any questions
about your prescription drug coverage, call Argus          Vision Benefits
Member Services at (800) 241-3371 or visit the             Your coverage may include benefits for vision
Prescription Drug section in the Members & Visitors        care under BlueVision or BlueVision Plus. Please
area of www.carefirst.com.                                  review your Evidence of Coverage to determine
                                                           if your coverage includes benefits for vision care.
How to Manage Medication Costs                             BluePreferred members with individual coverage
Our prescription drug benefit already saves you money       are only eligible for BlueVision coverage.
on prescription costs. However, you also may have
other alternatives to lower your costs while getting       CareFirst BlueChoice is pleased to offer BlueVision
medicines that treat your condition.                       and BlueVision Plus to meet your vision needs. These
                                                           vision plans are administered by Davis Vision, Inc., a
                                                           national provider of vision care services.




                                                 www.carefirst.com                                                        20
     Additional Benefits




     BlueVision                                                  How to Access Out-of-Network
     BlueVision provides a routine vision examination
                                                                 Vision Care
     (including dilation) once per benefit period for a           Out-of-Network care varies according to plan. Some
     $10 copay when you visit a participating Davis Vision       plans allow out-of-network care while others do not.
     provider. Through Davis Vision, you also receive            Refer to your Evidence of Coverage to find out what
     discounts on eyeglass lenses and frames or contact          benefits you have under your plan.
     lenses, as well as laser vision correction surgery. Refer
     to your Evidence of Coverage to find out what                If you choose an out-of-network provider, you will
     benefits you have under your plan.                           be required to pay the provider directly for all charges
                                                                 and then submit a claim for reimbursement to:
     BlueVision Plus
                                                                      Vision Care Processing Unit
     BlueVision Plus provides an extended benefit that                 P.O. Box 1525
     includes an eye examination (including dilation) and             Latham, NY 12110
     coverage for eyeglasses or contact lenses once per
     benefit period. Eyeglass frames and lenses are covered       Only one claim per service may be submitted for
     in full when you choose from Davis Vision’s Exclusive       reimbursement each benefit cycle. To print claim
     Tower Collection of approximately 270 frames, or            forms, visit the “Members & Visitors” section of
     you can receive an allowance toward any other frame.        www.carefirst.com and click on “Forms” or call
     You can also receive coverage for contact lenses in lieu    (800) 783-5602 to request claim forms.
     of eyeglasses when you choose Davis Vision contact
     lenses. The choice is yours! Additionally, Davis Vision
     offers discounts on laser vision correction surgery,
     additional lens treatments and coatings. Refer to your
     Evidence of Coverage to find out what benefits you
     have under your plan.

     With BlueVision Plus you may receive services from
     out-of-network providers in addition to in-network
     providers, although you will receive the greatest value
     and maximize your benefit dollars if you select a
     provider who participates in the network.

         How to Access In-Network Vision Care
         ■   Call (800) 783-5602 for a list of providers
             nearest you, or access the network through
             www.carefirst.com. Just click on Find a
             Doctor in the Solution Center.

         ■   Call the Davis Vision provider of your choice
             and schedule an appointment.

         ■   Identify yourself as a CareFirst BlueChoice
             member and a Davis Vision plan participant.

         ■   Provide the office with the member’s
             identification number and the year of birth
             of any covered dependents needing services.

         ■   The provider’s office will verify your eligibility
             for services and no claim forms are required.



21                                   FirstHelp ® Health Care Advice Line: (800) 535-9700
             Frequently Asked Your Plan
             Administration ofQuestions
Personal and Enrollment Changes                             Provider Reimbursement
If you change your name, address or phone number,           CareFirst BlueChoice providers are paid on a fee-for-
please contact Member Services and we will update our       service basis. This means that CareFirst BlueChoice
records or advise you of any forms you need to submit.      providers receive benefit payments according to a
Remember, we need your correct address to keep you          fee schedule for covered services they perform. You
informed about critical program information                 may contact Member Services to obtain additional
including policies, procedures and benefit changes.          information about provider payment arrangements.

If you have group coverage and you wish to enroll           Other Insurance
or disenroll a dependent (including newborns) or            When you or your dependents have additional
change your marital status, you must notify your            coverage under another health plan or insurance
employer within the time frame specified in your             program (for example, a plan through your spouse’s
Evidence of Coverage. Individual contract members           employer or Medicare) coordination of benefits
must notify CareFirst BlueChoice in writing to make         (COB) may apply. COB eliminates duplicate payments
enrollment changes.                                         for the same expense and plays an important role
                                                            in controlling the price you pay for your health
Filing a Claim for Reimbursement                            care coverage.
An advantage of your BlueChoice Opt-Out coverage
is that you do not have to file claims. CareFirst            While it is important that you receive the health
BlueChoice and CareFirst BlueCross BlueShield               benefits for which you are eligible, it is just as
providers are required to submit claims. All you have       important that payments are properly coordinated so
to do is pay any necessary copayment at the time            that one health insurance carrier does not exceed its
of the visit. If you do need to submit a claim for          payment responsibility for your bill. The combined
services rendered by a provider who does not                payment by CareFirst BlueChoice and the other plan
participate in the CareFirst BlueChoice or CareFirst        should not be more than the total amount of the bill.
BlueCross BlueShield network (such as emergency
care received outside the service area), you may contact    We update our COB information periodically;
Member Services for a CareFirst BlueChoice Health           however, should your other insurance change, please
Benefits Claim Form or print one from our web site           let us know so we can update our records. Even if you
at www.carefirst.com. Be sure to attach a complete           do not have other insurance, it is important that you
itemized bill prepared by the provider of service           provide that information to us so that we may keep
that includes the charges for each service along with       your records current, which will ensure the quick or
the medical condition for which the treatment was           expedited processing of your claims. To supply this
performed. Submit the completed claim form and              information, you may call our COB department
attachments to:                                             at (866) 285-2611, or you may download a COB
                                                            form in the Forms section of our web site at
     CareFirst BlueChoice, Inc.                             www.carefirst.com. Rules to determine how
     P.O. Box 804                                           benefits are coordinated are outlined in your
     Owings Mills, MD 21117-9998                            Evidence of Coverage.

All claims must be filed within the time limit specified in
your Evidence of Coverage.




                                                  www.carefirst.com                                                 22
     Administration of Your Plan




                                                                 Virginia:
         Member Satisfaction                                     Office of the Managed Care Ombudsman
                                                                 Bureau of Insurance
         CareFirst BlueChoice wants to hear your                 P.O. Box 1157
         concerns and/or complaints so they may be               Richmond,VA 23218
         resolved. We have procedures that address               (877) 310-6560 or (804) 371-9032
         medical and non-medical issues. If a situation          ombudsman@scc.virginia.gov
         should occur for which there is any question
                                                                 Center for Quality Health Care Services
         or difficulty, here’s what to do:                        and Consumer Protection
                                                                 Virginia Department of Health
         ■   If your comment or concern is regarding the         3600 W. Broad Street, Suite 216
             quality of service received from a CareFirst        Richmond,VA 23230
             BlueChoice representative or administrative         (800) 955-1819 or (804) 367-2104
             problems (e.g., enrollment, claims, bills, etc.),   Fax: (804) 367-2149
             you should contact Member Services. If you          mchip@vdh.virginia.gov
             send your comments to us in writing, please
             include your identification number and
                                                                 District of Columbia:
             provide us with as much detail as possible.         Medical Necessity Issues:
             Please include your daytime telephone               Department of Health
             number so that we may contact you directly          Office of the General Counsel
                                                                 Grievance and Appeals Coordinator
             if we need additional information.                  825 North Capitol Street, NE
                                                                 Washington, DC 20002
         ■   If your concern or complaint is about the           (202) 442-5977
             quality of care or quality of service received      Fax: (202) 442-4797
             from a specific provider, contact Member
             Services. A representative will record your         Issues other than Medical Necessity:
                                                                 Department of Insurance, Securities, and Banking
             concerns and may request a written summary          810 First Street, NE, Suite 701
             of the issues. If you send your comments            Washington, DC 20002
             to us in writing, please include your               (202) 727-8000
             identification number and provide us with
             as much detail as possible regarding any            Maryland:
             events. Please include your daytime telephone       Maryland Insurance Administration
             number so that we may contact you directly if       Inquiry and Investigation, Life and Health
             we need additional information. Our Quality         200 St. Paul Place, Suite 2700
             Improvement department will investigate your        Baltimore, MD 21202-2272
             concerns, share those issues with the provider      (410) 468-2000 or (800) 492-6116
             involved and request a response. We will then       Fax: (410) 468-2270
                                                                 www.mdinsurance.state.md.us
             provide you with a summary of our findings.
             CareFirst BlueChoice member complaints are          Health Education and Advocacy Unit
             retained in our provider files and are reviewed      Consumer Protection Division
             when providers are considered for continuing        Office of the Attorney General
                                                                 200 St. Paul Place
             participation with CareFirst BlueChoice.
                                                                 Baltimore, MD 21202
                                                                 (410) 528-1840 or (887) 261-8807
         These procedures are also outlined in your              Fax: (410) 576-6571
         Evidence of Coverage.                                   www.oag.state.md.us
                                                                 Office of Health Care Quality
                                                                 Spring Grove Center
                                                                 Bland-Bryant Building
                                                                 55 Wade Avenue
     If you wish, you may also contact the appropriate           Catonsville, MD 21228
     jurisdiction’s regulatory department regarding              (877) 402-8218
     your concern:                                               Fax: (410) 402-8215
                                                                 www.dhmh.state.md.us/ohcq

23                                   FirstHelp ® Health Care Advice Line: (800) 535-9700
             Frequently Asked Questions
                  Appeals Process
             Frequently Asked Questions
CareFirst BlueChoice’s appeal procedure is designed         Services Department. A Member Services
to enable you to have your concerns regarding a denial      representative will be available to assist you in
of benefits or authorization for services heard and          submitting your appeal in the event you are unable
resolved. By following the steps outlined below, you        to put the request in writing. All appeal decisions
can ensure that your appeal is quickly and responsively     will be rendered in writing to the member.
addressed. Please note that state mandates may alter
the steps below. Refer to your Evidence of Coverage         If the decision remains as a denial of the original
for more specific information regarding your                 request, a detailed explanation that references the rule,
appeal process.                                             policy or guideline used to make the decision will be
                                                            included. Also provided will be an explanation of the
An expedited appeal process has been established in         appropriate next steps a member may take if he or she
the event that a delay in a decision would be               is not satisfied with the appeal process.
detrimental to your health or the health of a covered
family member. In an expedited appeal, a decision by        Members have a right to an independent external
CareFirst BlueChoice shall be made within 24 hours          review of any final appeal or grievance determination.
from the time we receive the appeal. Review will be         If you wish, you may contact the insurance
done by a physician in the same or similar specialty        regulatory department in your area to file a complaint
as the treatment under review and not part of the           or an appeal regarding a denial or reduction of
original denial decision, as appropriate. Expedited         benefits. The procedure for filing an appeal is also
appeals involve care that has not yet occurred or is cur-   located on our web site at www.carefirst.com. In the
rently occurring (pre-service or concurrent care).          Members & Visitors section, click on “Frequently Asked
                                                            Questions” in the Solution Center. If you would like a
Step 1: Discussion of the problem                           paper copy of the appeal process, you may also contact
Your concerns can often be handled and resolved             the Member Services telephone number
through informal discussions and information                located on your member ID card.
gathering. If your question relates to our handling
of a claim or other administrative action, call and
discuss the matter with a CareFirst BlueChoice
Member Services representative. In many instances,
the matter can be quickly resolved.

Step 2: Appeal/grievance process
If your concern is not resolved through a discussion
with a CareFirst BlueChoice representative, you or
someone on your behalf may make a formal request
for appeal. CareFirst BlueChoice must receive the
request within 180 days of the date of receipt of
notification of denial of benefits or services. If the
request for appeal is related to a medical or clinical
issue, a physician in the same or similar specialty as
the treatment under review, not part of the original
denial decision, will review the request. This request
should be in writing and addressed to the Member




                                                 www.carefirst.com                                                      24
                         Your Coverage
                   Frequently Asked Questions
                                                                 or individual benefits under certain conditions.
                                                                 A conversion policy is a contract that provides
          Ending Your Coverage                                   individual or family medical coverage. Dental, vision,
          Your coverage or your dependent’s                      and prescription plans cannot be added to the
          coverage with CareFirst BlueChoice may                 conversion policy.
          automatically end for certain reasons. These
          reasons may include but are not limited to:
                                                                      Eligible members must enroll for conversion
          ■   you are no longer employed by the                       coverage within 31 days after their eligibility
              company that carries your CareFirst                     for group coverage ends. Members who
              BlueChoice coverage;                                    end or lose their group coverage may
                                                                      be entitled to a conversion policy in the
          ■   your employer cancels coverage                          following situations:
              with CareFirst BlueChoice;
                                                                       ■   the policyholder’s eligibility for his or
          ■   divorce from a policyholder; or                              her current group coverage ends;

          ■   a dependent child marries, is no longer a                ■   termination of spouse’s and dependents’
              full-time student or has a birthday placing                  eligibility due to the policyholder’s death;
              him or her beyond the age of coverage.
                                                                       ■   termination of marriage to the
          Please refer to your Evidence of Coverage or                     policyholder;
          contact Member Services for more
          information.                                                 ■   termination of the group agreement if
                                                                           the group has not provided for continued
                                                                           coverage through another plan, and
     Continuing Your Coverage                                              termination is not a result of the group’s
     If you are changing jobs or your dependents’ status                   failure to pay premiums; or
     changes, please speak to your employer, your payroll
                                                                       ■   termination of dependent’s eligibility
     office or Member Services about the options available
                                                                           due to reaching the age limit or marriage.
     to you and your eligible dependents to continue health
     care benefits.
                                                                 If you are interested in receiving a conversion policy
     If you have group coverage, you and your dependents         application, please contact Member Services at the
     may be eligible under federal laws to continue your         phone number listed on your member ID card.
     coverage with CareFirst BlueChoice at your own
     expense under the Consolidated Omnibus Budget               New Technology Assessment
     Reconciliation Act of 1985 (COBRA). Your former             To ensure that our members have access to safe
     employer is responsible for supplying eligible              and effective care, CareFirst BlueChoice has a formal
     beneficiaries with the details about COBRA coverage.         process to review and make decisions regarding new
     You and your dependents may be eligible for                 developments in medical technology. We evaluate
     continuation under a state or federal district provision.   new medical technologies and the use of existing
     See your Evidence of Coverage for more information.         technologies through a formal review process.
     Another option may be a CareFirst BlueChoice                We refer to medical personnel, governmental
     conversion policy. A conversion policy is a non-group       agencies and published articles about scientific
     policy offered to members who are losing their group        studies in this process.

25                                 FirstHelp ® Health Care Advice Line: (800) 535-9700
                 Portability (HIPAA)
             Frequently Asked Questions
The Health Insurance Portability and Accountability
Act of 1996 (HIPAA) ensures that individuals who
have health insurance do not experience a gap in
coverage due to termination or departure from their
current job. A member terminating coverage with an
insurance carrier will receive a Certificate of Creditable
Coverage indicating the length of time they have
had health insurance coverage. This Certificate of
Creditable Coverage is used to reduce any waiting
time for pre-existing conditions that may be part
of subsequent health insurance coverage, as long
as there has not been a break in coverage for more
than 63 days.

When a member terminates with CareFirst
BlueChoice, they receive a Certificate of Health Plan
Coverage that indicates how long the member was
covered. The member should then present the
certificate to the new insurance carrier. This will
reduce or eliminate waiting periods for pre-existing
conditions under the member’s new policy.




                                                 www.carefirst.com   26
                  Frequently Asked Questions
                       Confidentiality
     All health plans and providers must provide               To obtain a copy of our Notice of Privacy Practices,
     information to members and patients regarding             please visit our web site at www.carefirst.com or call
     how their information is protected. You will receive a    Member Services at the telephone number on your
     notice of privacy practices from CareFirst BlueChoice     member ID card.
     or your Health Plan, and from your providers as well,
     when you visit their office.                               Members of self-insured groups should contact their
                                                               Human Resources department for a copy of their
     CareFirst BlueChoice has policies and procedures          Notice of Privacy Practices. If you don’t know whether
     in place to protect the confidentiality of member          your employer is self-insured, please contact your
     information. Your confidential information includes        Human Resources department.
     Protected Health Information (PHI) and other
     nonpublic financial information. Because we are
     responsible for your insurance coverage, making sure          Your Rights
     your claims are paid, and that you can obtain any             You have the following rights regarding your
     important services related to your health care, we            own Protected Health Information. You have
     are permitted to use and disclose (give out) your             the right to:
     information. Sometimes we are even required by law
     to disclose your information in certain situations. You       ■   request that we restrict the PHI we use or
     also have certain rights to your own protected health             disclose about you for payment or health
     information, and there are some requirements you will             care operations;
     have to follow to allow other people to obtain your
     information on your behalf.                                   ■   request that we communicate with you
                                                                       regarding your information in an alternative
     Our Responsibilities                                              manner or at an alternative location if you
     We are required by law to maintain the privacy of your            believe that a disclosure of all or part of your
     PHI, and to have appropriate procedures in place to               PHI may endanger you;
     do so. In accordance with the federal and state Privacy
     laws, we have the right to use and disclose your PHI          ■   inspect and copy your PHI that is contained
     for payment activities and health care operations as              in a designated record set including your
     explained in the Notice of Privacy Practices. This                medical record;
     Notice is sent to all policyholders upon enrollment.
                                                                   ■   request that we amend your information
     Notice of Privacy Practices                                       if you believe that your PHI is incorrect
                                                                       or incomplete;
     CareFirst BlueChoice is committed to keeping the
     confidential information of members private. Under             ■   an accounting of certain disclosures of
     the Health Insurance Portability and Accountability               your PHI that are for reasons other than
     Act of 1996 (HIPAA), we are required to send our                  treatment, payment, or health care
     Notice of Privacy Practices to members of fully                   operations; and
     insured groups only. The notice outlines the uses
     and disclosures of protected health information,              ■   give us written authorization to use your
     the individual’s rights and CareFirst BlueChoice’s                protected health information or disclose
     responsibility for protecting the member’s                        it to anyone not listed in this notice.
     health information.



27                                FirstHelp ® Health Care Advice Line: (800) 535-9700
     Frequently Asked Questions
    Member Rights and Responsibilities
Rights of Members                                           Responsibilities of Members
The Plan promotes members’ rights                           Members have a responsibility to:
by providing mechanisms to ensure:                          ■ Provide, to the extent possible, information
                                                              that the Health Plan and its practitioners
■   Protection of confidential information.
                                                              and providers need in order to care
■   Accurate and understandable information                   for them.
    about benefit plans, customer service and
                                                            ■   Understand their health problems
    accessing health care services.
                                                                and participate in developing mutually
■   Continuity and coordination of                              agreed upon treatment goals to the
    medical and/or behavioral health                            degree possible.
    or substance abuse care by
                                                            ■   Follow the plans and instructions for
    participating providers.
                                                                care that they have agreed on with their
■   Professional and responsive                                 practitioners.
    customer service.
                                                            ■   Pay copayments or coinsurance at the time
■   Timely and complete resolution                              of service.
    of customer complaints and appeals.
                                                            ■   Be on time for appointments and to
Members have a right to:                                        notify practitioners/providers when an
                                                                appointment must be canceled.
■   Be treated with respect and recognition
    of their dignity and right to privacy.

■   Receive information about the Health Plan,
    its services, its practitioners and providers,
    and members’ rights and responsibilities.

■   Participate with practitioners in decision
    making regarding their health care.

■   Participate in a candid discussion of
    appropriate or medically necessary
    treatment options for their conditions,
    regardless of cost or benefit coverage.

■   Make recommendations regarding
    the organization’s members’ rights
    and responsibilities.

■   Voice complaints or appeals about the
    Health Plan or the care provided.



                                              www.carefirst.com                                              28
                               Definition of Terms
     Allowed Benefit: The maximum dollar amount                 Covered Expenses: Amounts that are eligible for
     allowed for services covered, regardless of the           benefits by CareFirst BlueChoice, as described in
     provider’s actual charge. A provider who participates     your Evidence of Coverage.
     in the network cannot charge the member more than
     this amount for any covered service.                      Covered Provider: A type of provider from whom you
                                                               are eligible to receive care under the benefits described
     Appeal: A protest filed by a member or a health care       in your Evidence of Coverage.
     provider under CareFirst BlueCross BlueShield/
     CareFirst BlueChoice’s internal appeal process            Deductible: The dollar amount of incurred covered
     regarding a coverage decision.                            expenses that the member must pay before CareFirst
                                                               BlueChoice makes payment.
     Authorization: The contractual requirement that the
     provider or member notify and obtain approval from        Dependent: A member who is covered under the Plan
     the plan before certain services are covered for a        as the spouse or eligible child of a Subscriber.
     member. Authorization is required for services such
     as, but not limited to, non-emergency hospitalizations,   Evidence of Coverage: A document reflecting an
     certain outpatient hospital services, skilled nursing     individual’s or group’s enrollment agreement with
     care, home health care, outpatient surgical services,     CareFirst BlueChoice.
     and durable medical equipment.
                                                               Exclusions: Specific conditions, treatments, services or
     Claim Form: A form obtained from Member                   circumstances listed in the contract for which CareFirst
     Services for reimbursement of covered services paid       BlueChoice will not provide benefits.
     by the member.
                                                               Health Care Provider: An individual who is licensed
     Coinsurance: A percentage of the plan allowance that      or otherwise authorized in this State to provide health
     the member pays for a covered service (e.g., 20 percent   care services in the ordinary course of business or
     for lab services or x-rays).                              practice of a profession, and is a treating provider of
                                                               the member; or a hospital.
     Complaint: A protest filed with the regulatory
     department involving an adverse decision, coverage        Health Maintenance Organization (HMO): An
     decision, appeal decision, or grievance decision.         organization that provides a wide range of health
                                                               care services through a PCP who renders or
     Coordination of Benefits (COB): A provision which          coordinates all of your care to provide you with
     determines the order of benefit determination when         quality service while reducing medical costs.
     a member has health care coverage under more than
     one plan.                                                 HIPAA: Health Insurance Portability and
                                                               Accountability Act. This Act addresses many tenets
     Copayment: A specified amount that the member              of health insurance coverage including the handling
     pays for a covered benefit (e.g., $10 per office visit      of Personal Health Information (PHI) and the
     to a primary care physician).                             Member’s ability to receive credit towards his or her
                                                               waiting period.




29                                 FirstHelp ® Health Care Advice Line: (800) 535-9700
                                                                                                     Definition of Terms




Indemnity: Traditional insurance plans under which          Blue Shield plan) to render covered services to eligible
the health plan reimburses the provider and the             members in accordance with the terms and conditions
member on a fee-for-service basis after the patient         of the Preferred Provider Plan.
has satisfied any applicable deductible. These plans
typically have the highest out-of-pocket expenses,          Preventive Health Care: Care provided to prevent
but they give you the flexibility to seek treatment          disease or its consequences. It includes programs
from any covered provider.                                  aimed at warding off illnesses (e.g., immunizations),
                                                            early detection of disease and inhibiting further
Member: An individual who meets all applicable              deterioration of the body. This includes the
eligibility requirements stated in Part 2 of the Evidence   promotion of health through altering behavior,
of Coverage, is enrolled for coverage, and for whom we      especially by health education.
receive the premiums and other required payments. A
member can be either a subscriber or a dependent.           Primary Care Physician: The Plan physician selected
                                                            by or on behalf of, the member to provide primary
Network: A group of multi-specialty medical groups          care to the member and to coordinate and arrange
and individual practice doctors who are contracted to       other required services.
provide services to members of a health plan.
                                                            Provider: An individual, institution or organization
Participating Provider: A covered provider that             that provides medical services. Examples of
contracts with CareFirst BlueCross BlueShield/              providers include physicians, therapists, hospitals
CareFirst BlueChoice to be paid directly for rendering      and home health agencies.
covered services to eligible members of this plan.
                                                            Referral: A written authorization by the PCP for the
Practitioner: Professionals who provide health care         member to see a specialty provider.
services. Practitioners are required to be licensed as
defined by law.                                              Specialist: A licensed health care provider to whom
                                                            a member can be referred to by a PCP.
Preferred Provider: A covered practitioner or facility
that contracts with CareFirst BlueCross BlueShield/         Subscriber: A member who is covered under the
CareFirst BlueChoice (or with another Blue Cross and        Plan as an eligible employee or member of the group,
                                                            rather than as a dependent.




                                                 www.carefirst.com                                                        30
                                                   Index
     Alternative therapies (Options) 12-14                   Hospital care, continued stay review 11
     Appeals 24                                              Laboratory services 7
     Appointments, canceling 7                               Medical emergency, definition 15
     Appointments, making 6                                  Medical records 6
     Appointments, scheduling guidelines 6                   Medical records, confidentiality 6, 27
     Argus Health Systems 20                                 Member satisfaction 23-24
     Away From Home Care® 17                                 Member ID card 1
     BlueCard® Program 16                                    Mental health care 17
     BlueVision 21                                           My Care First 8
     CareEssentials 8-11                                     My Account 4
     Case Management Program 11                              Options Discount Program 12-14
     Claim forms 22                                          Other insurance 22
     College students 17                                     Portability (HIPAA) 26
     Complaints 23-24                                        Prescription drugs 19-20
     Confidentiality 27                                       Prescriptions, drug formulary 20
     Contact lenses 21                                       Preventive services guidelines 9
     Coordination of benefits 22                              Primary care physician, changing 6
     Corrective lenses 21                                    Primary care physician, choosing 5
     Coverage, continuing 25                                 Primary care physician, role of 5
     Coverage, ending 25                                     Prior authorization 20
     Denial of benefits, appeals 23-24                        Provider directory 2, 4
     Dental care 19                                          Referrals 6
     Disease management programs 11                          Reimbursement, how to file a claim for 22
     Emergency, definition 15                                 Responsibilities, member 28
     Evidence of Coverage 29                                 Rights, member 28
     FirstHelp® 16                                           Specialists 2, 6
     Follow-Up Care 17                                       Substance abuse 17
     Frequently asked questions 2-4                          Traveling, care while 16
     Great Beginnings Program for Expectant Mothers 8        Urgent care centers 15
     Gynecological care 9                                    Utilization Management 10
     Hospital care, authorization for 10                     Vitality member newsletter 8




31                                FirstHelp ® Health Care Advice Line: (800) 535-9700
      For More Information, Call Member Services at the Telephone Number on Your Member ID Card.




                                                                                   Policy Form Numbers

          DC:
                                                                    Prescription Drug Rider: DC/CC/Ind Drug (11/04)

               MD:
                                                  and any amendments or riders. Prescription Drug Rider: MD/CC/Ind Drug (R. 10/04)

          MSGR:


         VA:
                                                                              Prescription Drug Rider: None


                                                                               Dental Policy Form Numbers

           DC:


           MD:


               VA:



                                                                               Vision Policy Form Numbers

                     DC:
                                                                               CFBC/EXCLUSION-V (9/04)

                      MD:


                                           VA:




                                                                               10455 Mill Run Circle
                                                                              Owings Mills, MD 21117
                                                                                www.carefirst.com
                                             CareFirst BlueChoice, Inc. is an independent licensee of the Blue Cross and Blue Shield Association.
                                 ® Registered trademark of the Blue Cross and Blue Shield Association. ®’ Registered trademark of CareFirst of Maryland, Inc.


VA FORM #: BOK5075-1S (12/09) web only

				
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